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INTAKE FORM

BEYOND TRAFFICKING ENTRY INFORMATION

Thank you for considering Beyond Trafficking as your place of faith-based restoration and healing.

  • The intake form below is intended to provide Beyond Trafficking with some basic information. Please fill out the entire form and add a phone number or email that can be reached after 5 p.m. (CST). Please feel free to ask any questions you may have during your intake call.

  • Once submitted, please allow 24 hours for contact to be made in order to complete the verbal portion.

  • If Saturday or Sunday (any time) is better for you, please specify. This call typically takes 15-30 minutes.

Association with Survivor
Rescue Status
Survivor is currently safe.
Survivor is in need of immediate rescue.

Survivor Information

Survivor's Name (If Different Than Above)

Birthday
Are you currently in a program?
Are you currently struggling with Substance Abuse?
Have you ever been to a Substance Abuse Program?
Yes
No
Have you been diagnosed with any mental illnesses?
Yes
No
Are you pregnant?
Yes
No
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